Indications for root canal treatment following traumatic dental injuries to permanent teeth.

The dental pulp may respond favourably or unfavourably to traumatic dental injuries. The most serious unfavourable responses are pulp necrosis and infection of the root canal system. These cause apical periodontitis and/or external inflammatory resorption of the tooth. The following injuries require root canal treatment as part of their emergency management-(A) complicated crown fractures (but some may be suitable for conservative pulp treatments, such as pulp capping, partial pulpotomy or pulpotomy), (B) complicated crown-root fractures, (C) supra-crestal coronal third root fractures and (D) injuries where pulp necrosis is predictable or highly likely to occur AND where there has been damage to the root surface and/or periodontal ligament with the aim of preventing external inflammatory resorption. This latter group of injuries are avulsion, intrusion, lateral luxation with a crown fracture, extrusion with a crown fracture (all in fully developed teeth) plus avulsion with a crown fracture and intrusion with a crown fracture (both in incompletely developed teeth). All other injuries should not have root canal treatment commenced as part of the emergency management, but they must be reviewed regularly to monitor the pulp for any adverse changes to its status, particularly pulp necrosis and infection of the root canal system.

Unusual Location of Dens Invaginatus Causing a Difficult-to-Diagnose Pulpal Involvement.

This article reports on an unusual case of dens invaginatus in a maxillary third molar that was causing severe symptoms of irreversible pulpitis. This malformation was not clinically or radiographically identified, and the occurrence of referred pain made the early identification of the responsible tooth difficult. Determination of the tooth that was the source of symptoms was only possible after an observation period and fast aggravation of the pathologic process to cause pulp necrosis and extreme tenderness to percussion. The diagnosis of dens invaginatus was made only after extraction and sectioning. Histopathologic and histobacteriologic features of this case are illustrated.

Orthograde apical plug in a traumatized tooth with necrotic pulp and immature apex using calcium silicate cement: A case report.

This case report describes dental management of a 15- year-old boy, undergoing treatment for Thalassaemia Major and Acute Myeloid Leukaemia with bone marrow transplant and immuno-suppressants. During the course of his treatment the patient developed a swelling in anterior maxilla and therefore was referred by the primary physician for evaluation. This case report highlights the management of medically compromised patients in a tertiary care hospital in which apexification was carried out in a permanent immature tooth utilizing MTA as an immediate apical plug.

Cutaneous draining sinus tract of odontogenic origin. A case of chronic misdiagnosis.

This is a case of a patient with a buccal cutaneous sinus tract, originally misdiagnosed, with delayed healing and potential malpractice. An odontogenic cutaneous sinus tract is a pathologic canal that initiates in the oral cavity but opens externally at the cutaneous surface of the face or neck. It is frequently misdiagnosed, leading to inappropriate treatment. Once correct diagnosis is made, definitive treatment, through oral therapy to eliminate the source of infection, is simple and effective. This case was initially misdiagnosed as a sebaceous cyst and laceration of parotid gland. The case was correctly diagnosed through detailed examination and evaluation, using tracing and advanced imaging technology (cone beam imaging). Endodontic treatment was performed, which resulted in rapid resolution of the case, followed by dermatologic treatment with fractional laser to treat the scar formed.

Complete Healing of a Large Cystic Lesion Following Root Canal Treatment with Concurrent Surgical Drainage: A Case Report with 14-Year Follow-Up.

We describe complete healing of an extensive cystic lesion by using a conservative approach: root canal treatment with concurrent surgical drainage. A silicone Foley catheter drain was modified into a surgical drainage stent, which was then used for 4 weeks. Disinfection of the root canal was achieved by the use of hand files and irrigation with 5.25% NaOCl for a minimum of 30 minutes. The irrigant changes were performed at 5-minute intervals, and no intracanal dressing was used. At subsequent follow-up examinations, cone-beam computed tomography and periapical radiographs confirmed that complete healing had occurred around the periapical and lateral areas of affected teeth. This case report indicates the potential for healing of large cystic lesions by nonsurgical root canal treatment.

Ibuprofen and Acetaminophen Versus Intranasal Ketorolac (Sprix) in an Untreated Endodontic Pain Model: A Randomized, Double-blind Investigation.

INTRODUCTION: Previously, ketorolac was available for primary use only via intravenous and intramuscular routes. Its availability in intranasal form offers an alternative route of administration that patients can self-administer. The purpose of this study was to compare the efficacy of intranasal ketorolac (Sprix; Egalet US Inc, Wayne, PA) with a combination of ibuprofen/acetaminophen in an acute pain model of untreated endodontic patients experiencing moderate to severe pain and symptomatic apical periodontitis. METHODS: Seventy patients experiencing moderate to severe pain, a pulpal diagnosis of symptomatic irreversible pulpitis or necrosis, and a periapical diagnosis of symptomatic apical periodontitis participated. Patients were randomly divided into 2 groups and received either 31.5 mg intranasal ketorolac and placebo capsules or 1000 mg acetaminophen/600 mg ibuprofen capsules and a mock nasal spray. Patients recorded perceived pain scores on a visual analog scale every 15 minutes from drug administration up to 240 minutes. The time to 50% pain relief, the first sign of pain relief, and meaningful pain relief were recorded, and the data were analyzed. RESULTS: A decline in reported pain was observed until 120 minutes after dosing, after which reported pain remained relatively constant. There was no significant difference between the 2 groups for the time to 50% pain relief, the first sign of pain relief, or meaningful pain relief. CONCLUSIONS: The effectiveness of intranasal ketorolac was not significantly different from that of a 1000 mg acetaminophen/600 mg ibuprofen combination. Intranasal ketorolac provides a nonnarcotic alternative and an additional route of medication administration to practicing clinicians.

Ludwig Angina after First Aid Treatment: Possible Etiologies and Prevention-Case Report.

Ludwig angina is a life-threatening type of soft tissue cellulitis involving 3 compartments on the floor of the mouth including the submental, sublingual, and submandibular spaces bilaterally. Prevention, early recognition, and treatment of Ludwig angina are critical because this is a clinical diagnosis with unpredictable progression. This article describes a rare case of Ludwig angina that evolved from an odontogenic infection and the specific microbiology and clinical course and discusses possible etiologies and prevention.

Management and Histobacteriological Findings of Mucosal Fenestration: A Report of 2 Cases.

This article describes 2 unusual cases of mucosal fenestration associated with necrotic infected teeth, resulting in exposure of the root apex to the oral cavity. Both cases consisted of maxillary incisors with pulp necrosis and radiographic/tomographic evidence of apical periodontitis. Clinically, the root apex was exposed to the oral cavity through a fenestration in both bone and mucosa and covered with bacterial plaque and calculus. These teeth were treated by a combination of nonsurgical and surgical endodontic treatment. During surgery, the root apices were resected to within the alveolus and the fenestrated area covered by the flap. Specimens consisting of the root apex and surrounding soft tissues were subjected to histopathological and histobacteriological analyses. Histobacteriological analysis revealed extensive resorptive defects on the root apices filled with thick bacterial biofilm, irregular detachment of the cementum layers with consequent infection of the underlying spaces, and heavy infection in the apical foramina. The soft tissue specimens exhibited no or minimal inflammation. The 2 cases showed satisfactory postsurgical healing of the hard and soft tissues. Both cases of mucosal fenestration showed root apices covered with dense bacterial biofilms and associated with a bone crypt with no significant inflammatory tissue therein. The 2 cases were successfully treated by conservative approaches involving a combination of nonsurgical and surgical endodontic treatment with root-end resection.

Case Report: Root resorption caused after pulp death of adjacent primary molar.

Necrotic decayed primary molars with necrotic pulp tissues may show periapical involvement and root resorption. In this case report, a pediatric patient with a very common chief complain and clinical picture of necrotic badly decayed molar, introduced a very interesting case when radiographic investigation was performed, which showed that root resorption of the adjacent healthy molar occurred. The current report is, to the best of our knowledge, the first to report such finding in primary dentition.

Orthodontic Movement after Regenerative Endodontic Procedure: Case Report and Long-term Observations.

INTRODUCTION: Although regenerative treatment approaches in teeth with incomplete root formation and pulp necrosis have become part of the suggested therapeutic endodontic spectrum, little is known about the effect of orthodontic movement in the tissue that has been regenerated. Furthermore, as the number of adults undergoing orthodontic treatment increases, there is an increasing need to investigate the changes that these tissues may undergo during orthodontic movement. Here we describe the alterations observed after the application of orthodontic forces in a case of an apically root-fractured necrotic immature root that had been managed with regenerative endodontic procedures in the past. METHODS: A 9-year-old male patient was referred after suffering the third incidence of trauma in the anterior maxilla. Radiographic evaluation revealed a periapical rarefaction associated with an apically root-fractured immature central incisor. Clinical evaluation revealed a buccal abscess and grade 3 tooth mobility. Periodontal probing was within normal limits. The tooth was accessed and disinfected by using apical negative pressure irrigation of 6% NaOCl. Intracanal dentin conditioning was achieved by using 17% EDTA for 5 minutes. A blood clot was induced from the periapical area, and calcium silicate-based cement was placed in direct contact with the blood clot at the same visit. The composite resin restoration was accomplished in the same appointment. RESULTS AND CONCLUSIONS: Recall radiographic examination after 24 months revealed healing of the periapical lesion and signs of continuous root development despite the apical root fracture. Clinical evaluation revealed normal tooth development, normal mobility, and a resolving buccal infection. The tooth was subjected to orthodontic treatment because of Class II division 1 malocclusion with an overjet of 11 mm. After completion of the orthodontic treatment, 5.5 years after the initial intervention, the radiographic image revealed marked remodeling of the periapical tissues and repair of the apical fractures, and the buccal infection had resolved completely.

Management of a Permanent Maxillary Lateral Incisor with Vital Pulp and Necrotic Dens Invaginatus Type III.

This is a case report on the management of a vital lateral incisor with a radiolucent cervical area associated with the presence of necrotic pulp due to a dens invaginatus (DI) type III. A nine-year-old boy presented to a university pediatric dental clinic with dental trauma. The examination showed poor oral hygiene, an uncomplicated fracture in the permanent maxillary left central incisor, and a fistula near the permanent maxillary right lateral incisor. A radiograph showed that the right lateral incisor had incomplete root development and a type III DI. Although sensitive to thermal pulp testing, tracing of the fistula indicated that the radiolucent area was associated with the DI, extending laterally to the periodontal ligament. Endodontic treatment was performed only in the invagination, keeping the root canal of the lateral incisor vital. After two years of follow-up, complete root formation and injury repair associated with invagination were observed.

Fístula cutánea odontogénica: un reto diagnóstico / Odontogenic cutaneous fistula: a diagnostic challenge

La fistula cutánea odontogénica (FCO) es el resultado de una canalización anormal originada a partir de una infección crónica periapical. Representa todo un reto diagnóstico ya que frecuentemente son lesiones etiquetadas erróneamente como dermatológicas. El diagnóstico diferencial es amplio, incluyendo el granuloma piogénico, tuberculosis cutánea o malformaciones congénitas entre otros. Exponemos el caso de un varón de 46 años diagnosticado de FCO que presentó una rápida mejoría tras exodoncia de las piezas dentales afectas y fistulectomía. Consideramos importante el conocimiento de esta patología para evitar retrasos innecesarios en el diagnóstico y tratamiento adecuado (AU)

Odontogenic cutaneous fistula (OCF) is the result of an abnormal canalization originating from chronic periapical infection. It represents a diagnostic challenge, as it is frequently misdiagnosed as dermatological lesion. There is a broad differential diagnosis, including pyogenic granuloma, cutaneous tuberculosis or congenital malformations, among others. We report the case of a 46-year-old man diagnosed with OCF who presented a rapid improvement after extraction of the affected dental pieces and fistulectomy. We consider knowledge of this pathology to be important in order to avoid unnecessary delays in diagnosis and proper treatment (AU)

Healing of Apical Periodontitis after Nonsurgical Treatment in Patients with Type 2 Diabetes.

INTRODUCTION: The purpose of this prospective study was to compare the success of primary root canal treatment between type 2 diabetic and nondiabetic patients and to investigate the effect of periapical healing on glycated hemoglobin (HbA1c) in type 2 diabetic patients with apical periodontitis. METHODS: Sixty mandibular molars with necrotic pulps and apical radiolucency (size ≥ 2 mm × 2 mm) were included in the study. Based on the HbA1c levels, patients were divided into 2 groups: type 2 diabetic (HbA1c ≥6.5%) and nondiabetic (HbA1c <6.5%). Forty-six teeth were evaluated at the 12-month follow-up time period. The primary outcome measure was the change in apical bone density as determined by the periapical index. RESULTS: Both the diabetic and nondiabetic group depicted a significant reduction in the periapical score after endodontic treatment at the 12-month follow-up (P < .05). Significantly less periapical healing was observed in the diabetic group (43%) compared with the nondiabetic group (80%) at the 12-month follow-up (P < .05). HbA1c levels in the diabetic group increased at each follow-up after endodontic treatment. CONCLUSIONS: Diabetes mellitus may have a negative impact on the outcome of endodontic treatment in terms of periapical healing. Nonsurgical endodontic treatment did not improve HbA1c levels in patients with type 2 diabetes.

Management of Dens Invaginatus Type II Associated with Immature Apex and Large Periradicular Lesion Using Platelet-rich Fibrin and Biodentine.

Dens invaginatus (DI) poses peculiar challenges in endodontic treatment of teeth because of distortion of pulpal space. A case of Oehlers type II DI with open apex and large periapical lesion is reported. The case was managed using cone-beam computed tomography (CBCT), operating microscope, platelet-rich fibrin (PRF), and Biodentine. A 15-year-old male patient presented with palatal swelling. Pulp sensibility testing of right maxillary lateral incisor was negative. Intraoral periapical digital radiograph revealed an Oehlers type II DI with open apex and periapical radiolucency. A CBCT scan was performed to study the anatomy, determine the true extent of the periapical lesion, and form a treatment plan. A diagnosis of Oehlers type II DI with pulp necrosis and acute periapical abscess was made. Two-visit endodontic treatment was performed. In the first visit, the invaginated central mass was removed under operating microscope, chemo-mechanical preparation was done, and double antibiotic paste dressing was placed. In the second visit, the canal was sealed with apical matrices of PRF and Biodentine as filling material. The patient was asymptomatic and radiographs revealed continued healing of the osseous defect at follow-up visits. A CBCT scan at 30 months showed complete continuity of periodontal ligament space, healing of labial and palatal cortical plates, and formation of intercortical bone. The advances in endodontic armamentarium and technology, like CBCT and operating microscope, have made successful treatment of challenging cases possible. PRF and Biodentine as apical matrices and filling material, respectively, proved to be effective in the present case.

Quiste odontogénico inflamatorio: aislamiento de Pseudomonas stutzeri. Relevancia diagnóstica / Isolation of Pseudomonas stutzeri from an odontogenic inflammatory cyst: Diagnostic relevance

Pseudomonas stutzeri se encuentra ampliamente distribuido en el medio ambiente, ocupando diversos nichos ecológicos; pero su aparición en procesos infecciosos de interés clínico es el de patógeno oportunista. El aislamiento de P. stutzeri en un quiste inflamatorio odontogénico es un verdadero hallazgo microbiológico que no presenta antecedentes en la bibliografía científica odontológica. En este caso particular, el aislamiento se obtuvo a partir de material quirúrgico proveniente de un quiste odontogénico inflamatorio ubicado en la pieza dentaria 1.2 con necrosis pulpar concomitante. Se emplearon técnicas diagnósticas complementarias como radiografías, tomografías, estudios anatomopatológicos y microbiológicos. Los resultados permitieron clasificar el proceso como quiste inflamatorio infectado con P. stutzeri. La tipificación y la caracterización del perfil de sensibilidad de la cepa aislada permitieron adecuar la terapéutica antibiótica de manera específica. El análisis microbiológico permitió establecer la etiología del proceso infeccioso, la adecuación del tratamiento y el restablecimiento de los tejidos comprometidos.

Pseudomonas stutzeri is distributed widely in the environment, and occupies different ecological niches. However, it is found in clinically relevant infections as an opportunistic pathogen. Isolation of P. stutzeri from an odontogenic inflammatory cyst is an uncommon microbiological finding that has not been reported to date. In the case presented here, the bacterium was isolated from surgical material obtained from excision of an inflammatory odontogenic cyst located in the tooth 1.2, and presenting with concomitant pulp necrosis. Complementary techniques such as radiographs, CAT scans, and histopathological and microbiological studies were used to establish definitive diagnosis. The obtained results allowed classifying the process as an inflammatory cyst infected by P. stutzeri. Biotyping and characterization of the susceptibility profile of the isolated strain allowed adjusting the antibiotic therapy more specifically. The microbiological studies allowed establishing the etiology of the infectious process, adjusting the treatment plan, and re-establishing tissue integrity.

Collaborative Management of Combined Periodontal-endodontic Lesions with a Palatogingival Groove: A Case Series.

INTRODUCTION: This article reports 3 representative cases of interdisciplinary management of a palatogingival groove in maxillary lateral incisors. The development, pathology, and effectiveness of management approaches in cases involving a combined periodontal-endodontic lesion with a palatogingival groove are discussed. METHODS: We describe 3 patients with a noncontributory medical history presenting with a chief complaint related to a maxillary incisor and diagnosed with a combined periodontal-endodontic lesion with a palatogingival groove at Seoul National University Dental Hospital, Seoul, Korea. RESULTS: Palatogingival grooves were mostly associated with deep periodontal pockets connected to a periapical lesion. Optional collaborative treatments were performed according to the condition as follows: case 1, root canal treatment (RCT), open flap debridement, odontoplasty, and guided tissue regeneration; case 2, RCT, apicoectomy, open flap debridement, and odontoplasty; and case 3, RCT, crown restoration, root planning, and odontoplasty. After clinical examination and radiographic assessments, the periapical lesion and periodontal deep pocket were successfully resolved with periodontal-endodontic collaborative treatment involving both periodontal surgical procedures (cases 1 and 2) and a nonsurgical procedure (case 3). CONCLUSIONS: Within the limitations of this study, these case reports show that accurate diagnosis of developmental anomalies and elimination of inflammatory irritants are key factors for favorable long-term outcomes.

Extraoral cutaneous sinus tracts of dental origin in the paediatric patient. A report of three cases and a review of the literature.

BACKGROUND: An extraoral sinus of odontogenic origin within the face and neck region is normally the consequence of long-standing chronic infection due to caries, trauma or periodontal infection. There is little reported literature on the prevalence of extraoral cutaneous sinus lesions in the paediatric dental patient as presentation is often delayed resulting in misdiagnosis and consequential mismanagement. CASE REPORT: The cases discussed concentrate on the aetiology, history, presentation and diagnosis of extraoral sinus lesions that presented in children referred to the Child Dental Health Department at the University Dental Hospital of Manchester over a six-month period. CONCLUSIONS: The importance of correct diagnosis and treatment management of an extra oral cutaneous sinus in the paediatric patient only occurred when the child attended a specialist led paediatric dental clinic for consultation.

Management of dens in dente associated with a chronic periapical lesion.

Dens in dente is characterised as a developmental anomaly resulting from invagination of the enamel organ into the dental papilla. It is a rare malformation of teeth, showing a wide spectrum of morphological variations such as gemination, microdontia, taurodontism, dentinogenesis imperfecta, supernumerary tooth and hyperplasias, resulting frequently in early pulp necrosis. Maxillary lateral incisors are the commonest teeth to be affected by dental malformations-supernumerary tooth, talon cusp, congenitally missing tooth and dens in dente. We describe the management of a case of dens in dente in a maxillary lateral incisor with a periradicular lesion.